What is THAT?

It’s sad when I see a patient who “let it go” in regards to troubling skin issues. I know it’s a problem in healthcare generally, but I usually see the skin. It’s sad when people fear the cost and it ends up costing their lives, it also mystifies me when those with good health coverage put off care. I do understand on a very basic level, I was a stubborn 18-24 year old male and a Marine on top of that. So of course I was much to tough to deal with issues, and I pay with premature aches and pains. I’d gladly take that over cancer however. 

An elderly elderly (yes two, thanks TWIV) woman has a growing red lesion on her breast that is tender, erythematous, enlarging, and eventually starts to ooze. It’s easy for me to say initially, why did that have the chance to grow so big? That’s the wrong question I think, blame is easy but not commonly a good idea. For a young 30 something woman, an enlarging, tender, firm mass would be concerning. If you have dyskinesia and need help to get dressed, that is different. 

On a tangent, what the hell were those people who make assisted living assisted doing? Trust me when I say the mass was not subtle. I really do understand how swamped and stressed people can become but how did that escape under the rug? Anyway; I would go on but I’ve said before, pay attention. Situational awareness is not only important for your safety but for “their” safety. 

In past lives I have seen inflamed and infected cysts and that is probably what it first appeared like. Cysts tend to cycle between inflamed and calm, usually drain whiteish, purulent, pungent, or blood tinged fluid of various viscosities. Depending on the type of cyst, this is usually from a central pore, that which become clogged and allowed the cyst to build. The key with cysts is typically they improve with PO antibiotics.  

For this lesion, it progressed despite IV and PO antibiotics. This makes me think of malignancy, fungal or viral lesion/infection, or just a resistant bacterial infection. I’m sure there are other differentials, maybe an inflamed, necrotic ulcer or various subtypes of all those things. 

Not a doc, but it looks like a metastasis and that’s what the actually doc thinks. So a biopsy will be done. The most common malignancies to have cutaneous metastases are melanoma, lung, breast, and colorectal cancers. It makes some sense that the skin is vulnerable, being our largest organ. Setting aside melanoma, cutaneous lesions are not commonly the first sign of an internal malignancy. If a skin lesion from an internal malignancy was examined, the pathology likely would indicate its origin depending on its differentiation. For example, seeing liver cells after a shave biopsy. The cells can also be so far gone that one can’t tell that it isn’t skin cancer or where it came from. 

Ideally, the only cancer on the skin we would worry about is the classic skin cancers (actually, ideally no cancers). When others metastasize to the skin, it’s a bad sign. Though it may be the only indication of something internal, then at least we can attempt to treat the underlying problem. 

It helps me to talk (or write) this stuff out so I hope you may have learned a thing. Check out the podcast please and thanks! Love y’all.

References

Various cyst pages on the NIH: National Library of Medicine 

Image of manifestation of colorectal cancer spread to the skin

Metastatic Skin Cancer from the American Osteopathic College of Dermatology 

Metastatic Tumors to the Skin from the NIH by Neel and Sober.  

Unique skin metastasis from recurrent cancer, case report by Papadopoulos 2020 @ Dove Press